The pathogens that cause viral hepatitis come from to a number of different virus groups. The severity and duration of an infection depends on the type of virus contracted: the Hepatitis B and Hepatitis C viruses are the most common causes of liver cirrhosis and liver cancer. Experts addressed the topic viral hepatitis and its significance in relation to public health at the conference “Virus-Hepatitis und der Öffentliche Gesundheitsdienst in Österreich” (Virus Hepatitis and the Public Health Service in Austria) at AGES, the Österreichischen Agentur für Gesundheit und Ernährungssicherheit GmbH (Austrian Agency for Health and Food Safety) on 27th July.
Hepatitis infections must be reported to the authorities in Austria. A total of 561 cases of Hepatitis A, 6,311 cases of Hepatitis B, 9,425 cases of Hepatitis C, 36 cases of Hepatitis D and 143 cases of Hepatitis E were reported between 2009 and 2016. Of these cases, 196 were reported as deaths. There is a vaccine for Hepatitis A and B; and a new and effective combination therapy for the treatment of Hepatitis C has been introduced recently.
Conference 27th July, 2017 – link to Programme & Registration
Hepatitis A is transmitted via contaminated foods and contact/smear infections. Hepatitis A infections may be caused by contaminated foods, such as a European-wide outbreak totalling more than 1,300 cases in 2013/2014, caused by deep frozen berries. “A clear increase in Hepatitis A virus activity has been observed in 15 European countries, including Austria, since June 2016. The virus predominantly affects young, adult men, who have sex with other men,” said Univ. Prof. Stefan Aberle of the Center for Virology at the Medical University of Vienna. All in all, more than 1,500 confirmed Hepatitis A cases have been reported in the course of this European-wide outbreak. “Austria also saw an increase in Hepatitis A cases. A total of 124 infections, mostly in men in the age group between 25 and 44, were already reported by June this year alone,” said Aberle. In general, Hepatitis A recovery takes just a few weeks, leaving the patient with a life-long immunity to the Hepatitis A virus. The average fatality rate is around 0.3%. The incubation period of this fecal-orally transmitted disease is 3 – 6 weeks. Hepatitis A shows no chronic symptoms, the disease usually disappears completely. Inoculations are very effective, but not included in the free vaccination programme.
The disease is mainly transmitted via non-sterile medical instruments (tubes, syringe needles), although contaminated blood, spermatozoa/cervical secretions (“sexual”) and saliva (“oral”) are also possible vectors. A major factor is the transmission from a mother to her unborn child (“prenatal”). The vaccine for Hepatitis B is included in the free vaccination programme and given as part of the 6-in-1 vaccination in line with the 2 + 1 scheme in the 3rd, 5th and 12th (-14th) months of childhood. It is recommended to have a booster jab between the age of six and 15, following basic inoculation during infancy. Hepatitis B will become chronic in approximately 10 % of otherwise healthy adults with the disease. “Patients with a chronic Hepatitis B virus infection are usually asymptomatic or suffer from unspecified symptoms, such as general tiredness, slight pain in the right side of the abdomen. Symptoms may only appear if a chronic Hepatitis B virus infection has damaged the liver to the extent that the patient suffers from advanced liver cirrhosis or liver carcinoma,” explained Univ. Prof. Heinz Zoller from the Medical University Innsbruck. At such a late stage, the only way to stop the disease might be a liver transplant. However, not all patients develop such chronic viral Hepatitis B infections. The incubation period of this disease is 2 – 3 months.
This disease is transmitted via similar vectors to the Hepatitis B virus. The estimated seroprevalence of Hepatitis C is between 0.1 % and 1.1 % of the average population in Western Europe. The seroprevalence is especially high in people who have taken intravenous drugs over a longer period of time. Another risk group is prisoners: “In the prison system, 51 of 77 long-term convicts with Hepatitis C infections were treated with the new combination therapy in 2016. The costs of the medication alone amounted to 1,200,000 million euros,” said Dr. Margit Winterleitner, Chief Medical Officer at the Federal Ministry of Justice. The incubation period for this disease varies between two weeks and six months.
The Hepatitis D virus requires the hull of the Hepatitis B virus to cause an infection. Thus, Hepatitis D always appears together with Hepatitis B and takes a severe chronic course in 70 to 90 % of all cases.
This virus is transmitted via similar vectors to the Hepatitis A virus. Most people who get Hepatitis E infections show no or only very mild symptoms. Hepatitis E infections mainly affect patients with weak immune systems, in particular transplant patients, who may even die following infection. In a recently published scientific statement, the European Food Safety Authority EFSA states that raw or insufficiently cooked pork is the main cause of Hepatitis E infections in humans: over 21,000 infections were reported over the past 10 years in the EU Member States. The AGES Institute for Veterinary Examinations Mödling researched the occurrence of Hepatitis E genotype 3 antigens and antibodies in domestic pigs and wild boars. “A study on 1,152 slaughter pigs from 72 conventional farms in Austria found that the liver or faeces of 64 pigs (6 %) from 30 farms tested positive for the Hepatitis E virus genome,” said Univ. Prof. Friedrich Schmoll, Head of the Animal Health Division at AGES. The Hepatitis E virus could be detected in 17 (23 %) of the 75 wild boars tested, using PCR. The incubation period for this disease varies from two weeks to two months.
Donating Blood and Hepatitis Screening
Around 220,000 blood donors give 350,000 blood donations in Austria every year, which are screened for Hepatitis A, B and C and also for Hepatitis E to some extent by blood donation services, in addition to other infectious diseases. The Hepatitis A virus was detected only once in 1.33 million blood donations between 2009 and 2017. One in 10,400 donations tested positive for the Hepatitis B virus. The detection ratio for the Hepatitis C virus was one in 37,884 (644,026 tested donations) between 2013 and 2017, for Hepatitis E one in 5,369 (155,691 tested donations) from 2016 – 2017. “Tests for Hepatitis B and C are carried out using both serologic and molecular biological methods. As a result, the residual transmission risk for Hepatitis C via blood products could be brought down to 1:10 million,” said Ursula Kreil from the Blood Donation Centre of the Austrian Red Cross for Vienna, Lower Austria and Burgenland.
The recording of hepatitis infections by the authorities provides the basis for targeted intervention by public health agencies. “The challenge today is to have representative records showing the continuity of treatment for Hepatitis B and C, analogue to our approach for HIV infections,” explained Univ. Prof. Robert Zangerle from the Medical University Innsbruck. While very sophisticated diagnosis-based models exist for HIV, making the calculation of the total number and timing of undiagnosed infections possible, this can only be done at a very rudimentary level for Hepatitis B and C. The Austrian Hepatitis C Surveillance Service is based on the mandatory reporting of cases of newly diagnosed, acute Hepatitis C or chronic viral Hepatitis C infections. There has been a mandatory obligation for laboratories to record cases of Hepatitis C infections in the electronic epidemiologic notification system (EMS), in addition to legal reporting obligations by doctors. An up-to-date evaluation of the Hepatitis C Surveillance Service by AGES (Department for Infection Epidemiology & Surveillance) on behalf of the Ministry of Health has determined there is room for improvement. The authors recommended merging national Hepatitis C surveillance data from the epidemiologic notification system EMS with Hepatitis C data from other sources, such as prisons and Hepatitis C treatment centres. The objective is a reliable, ongoing assessment of epidemiologic development of Hepatitis C in the Austria population.